Ice is an extremely hot (or rather, cool) topic in sports medicine and acute injury rehab, and for good reason. The way we treat injuries is continually changing based on the most up to date research. Due to this, it’s no wonder there is confusion around whether ice is good, bad or indifferent for injuries.
When someone rolls their ankle, most of us instinctively grab an ice pack. When we see professional athletes get injured, they’re wrapped in ice before they’ve even made it off the field. Ice appears to be an ingrained part of the acute injury management process, but does this align with the latest research?
The earliest documentation of ice as part of the acute injury management protocol dates back to 1978 when the term RICE (Rest, Ice, Compression, Elevation) was coined by Dr Gabe Mirkin (1). His intention behind using ice was to minimise the inflammatory response in an attempt to accelerate healing. This initial protocol became deeply rooted in our culture and for 20 years we were ‘RICE-ing’ injuries before P was included for protection (PRICE). 14 years later, POLICE (Protection, Optimal Loading, Ice, Compression, Elevation) replaced PRICE (2).
The reason for the changes?
Research has since identified that ‘Optimal Loading’ (OL) aids recovery through cell regeneration induced by light mechanical loading in the early stages. Subsequently, Rest (R) or a lack of movement is detrimental to recovery (3).
But what about ice?
There is certainly a consensus throughout the literature that ice acts as a great analgesic (pain numbing agent) by cooling the skin’s temperature. However, the impact on underlying muscles is non-existent, as muscle temperature remains unchanged from topical ice application. What we are much less certain of now then we were in 1978, is it’s healing properties. Anecdotally (and likely due to the analgesic effect) most people report ice makes injuries “feel better”, at least in the short-term. But what impact does immediately icing an injury have in the mid to long-term?
In 2014, Dr Mirkin acknowledged changes in the research and, as any evidence-based scientist would, retracted ice from his initial protocol. He stated that coaches had been using his “’RICE‘ guideline for decades, but now it appeared that both ice and complete rest may in fact delay healing, instead of helping” (3).
What Dr Mirkin is referring to is the necessary benefits of the inflammation process. When we injure ourselves, our body sends signals out to our inflammatory cells (macrophages) which release the hormone Insulin-like Growth Factor (IGF-1). These cells initiate healing by killing off damaged tissue. Although when ice is applied, we may actually be preventing the body’s natural release of IGF-1 and therefore delaying the initiation of the healing process (3).
Ice was finally revoked in 2019 from the injury management process with the latest and most comprehensive acronym: PEACE & LOVE (Protection, Elevation, Avoid Anti-Inflammatory Drugs, Compression, Education & Load, Optimism, Vascularisation and Exercise) (4).
With all of this new-found evidence on the negatives of icing injuries, it begs the question:
‘If ice delays healing, even if it can temporarily numb pain, should we still be using it?’
Probably not.
I will however caveat this with one thing. While some inflammation may be warranted for recovery, too much or prolonged oedema (swelling) is bad news. Excessive oedema applies unwanted pressure on the tissues, restricts movement, can increase pain and decreases muscle function (5).
This is often seen in severe joint sprains (such as ankle sprains) where swelling is significant enough that range of movement is impeded. Another example is arthrogenic muscle inhibition of the quadriceps following ACL surgery.
In these circumstances ice may be a viable option, as the goal is not to necessarily prevent all swelling, but to limit the extent of it (6). In contrast, muscle tears often elicit less oedema and hence ice is likely not going to be of benefit in the early stages (or at all) during injury management.
So for now, based on the current research, I’d keep ice in the freezer for the most part. As we currently understand it, ice is less important than we once thought. The exception to this rule would be when injuries are severe and in circumstances where swelling will likely be the limiting factor for recovery. In these cases, ice may be beneficial in the early stages only.
What then should be our primary focus?
Encouraging people to return to movement safely again, as soon as it is practical.
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Interesting read! 🤔 I’ve found the ice debate depends on the injury. Personally, a brand name Hampton Adams gear has been a helpful addition to my recovery routine. 🩹 Listen to your body and here’s to a quick recovery for all! 💪
Sorry for the comment….
Depending on the case to be treated, of course yes.
If the case at hand warrants using heat, of course I will use heat.
If I’m not sure what to use, then I won’t use one or the other.
I’ll wait and watch.
I think the following must be considered:
The acute injury or condition is accompanied by an inflammatory response: YES / NO (muscle cramp, muscle contracture, mild myalgia, among others, I can use both agents and each one will have pros and cons).
The tissue to be treated is within reach of the effect of the physical agent that I am going to use: YES / NO (there are deep structures that the superficial change in temperature does not affect).
Does the physical agent I am going to use have a useful effect at that time?: YES / NO (my goal is only analgesia? Is it to reduce local oxygen consumption? Is it to reduce vascular congestion a little?, etc.)
Is the injured segment to be treated affected by hydrostatic pressure?: YES / NO (a shoulder injury versus an ankle injury have different hydrostatic pressures… unless we are treating bats…)
There may be other questions to answer before ruling out the use of cold… or ruling out the use of heat.
Only the clinician, based on his knowledge and experience, but above all, given the situation and context, will determine what decision to make.
In my opinion, the essence of the initial management of sports conditions/injuries remains intact, there are only changes and nuances, but the fundamental intention is the same.
REST: It can range from absolute rest or immobilization (for the minimum necessary time) to loading and movement guided by a functional bandage. The essence remains. Injured tissues will initially be protected (the minimum necessary) and then progressively overloaded as efficiently as possible to achieve normalization as quickly as possible (without being reckless).
ICE: To cool or not to cool, the clinician will decide. Many factors influence this decision, but a fundamental one is the combination of situation/context.
COMPRESSION: May help prevent edema formation. But this is not very evident in the upper limbs and trunk. It is more evident in the most distal part of the lower limbs (remember the exception in bats).
Is it possible to apply compression to the iliopsoas, obturator internus, iliofemoral ligament, round ligament, subscapularis muscle, glenohuemeral ligaments, etc. As long as the magnitude of the edema does not produce alterations in functional capacity, I do not see a problem in its presence. Another issue is joint effusion, which is a different thing.
ELEVATION: It can help avoid the formation of edema, which can be important to manage when it exceeds certain magnitudes, such as in large traumas. These types of cases also require periods of immobilization or little mobilization for a certain period. On the contrary, in minor injuries, will 15 or 30 minutes of elevation really contribute if the person subsequently has to stand for 8 hours? … I do not believe it.
Another aspect to consider comes from extrapolating to humans the results of observations that come from studies carried out in animals. They have different biologies than ours. Therefore, they have biochemical, histological, physiological, pathophysiological, etc. differences. I don’t think everything can be extrapolated from laboratory animals to humans. The results and observations must be taken into account, but with caution.
Added to the above is the effort of a few to appear as an ESNOB (s/nob… then snob = sine nobilitate) and try to modify something that in its essence does not require modification… like when the ancient conquerors arrived at an unexplored territory , but it already had inhabitants..
I think it is difficult to construct an acronym that simplifies the complexity of addressing acute sports injuries with completely different pathophysiologies that require even opposite interventions.
Finally, it seems to me that each case must be evaluated… And it is the clinician who will have that task.
Saludos !!
With regards to ice application, the PEACE & LOVE authors cited a research study on rats with 1 ice application of 20 minutes applied 5 minutes after a contusion injury was inflicted on them. The results of this study cannot be applied to different types of injury, let alone a human population. And in fact, when you read the discussion of the cited study, they seem to have overlooked / not reported other important statements. This misreporting / representation of research is irresponsible as it leads to propagation of inaccurate information such as this article.
Interesting ..I also looked on it and find it in delaying heeling process..
But interesting as initially it only limits inflammation and pain through vasoconstriction followed by vasodialation that helps in healing ..
nice so to avoid excessive swelling and pain use ice. A deeper question perhaps is does ice really prevent the release of macrophages and the inflammatory response (maybe it does for 5 minutes but then it comes back afterwards). Seems like until we see what it actually does we are just making educated guesses
Hi, just wondering if a bridge of nose injury occurs, (breakage Unknown) would ice still be held back?
Interesting Sports physicians recommend ice at the time of acute injury and no longer than two days post injury
I’ve looked up the research studies cited and I’m not seeing an actual study that confirms that supports the article. the brittish journal of sports medicine article you sited even says to ice in their study.
Shhhh, everybody online knows that folks won’t look up the references so there’s no need to make them actually apply or support what is being claimed.
could there be an argument that, if applying ice for 10 minutes every few hours, you could be kickstarting the process each time – and therefore enhancing it? shutting it down by applying ice so supercharging the response in the few hours in between?
Exactly. This is just a reactionary throwing out the baby with the icewater. In the immediate post injury phase you’re not healing anything and need to shut down runaway inflammation. Just don’t use it forever like they used to do. Even Mirkin’s website article is talking more about long-term use than the immediate acute injury phase.
Great article and something I have been trying to tell people for a minute, without much avail 🙁
My question, however, is about using ice with gross swelling. I was under the impression, from an old article in the late 70’s 0r early 80’s, that indicated the application of ice actually increased lymphatic permeability and in result would dump any inflammation that was removed right back to the area of swelling. Thoughts???
There is no single research refenced about using ice on injury in reference 😛
Thank you very interesting . Just one question. Why is ICE not been recommended anymore as we want the inflammatory process but elevation and compression is still recommended ? Thank you
@ginnyschniewind to remove swelling that causes unwanted pressure and pain. Inflammatory cells comes with blood but we can remove the lymph 🙂
Very interesting and it changed my thoughts about the ice 👍👍